Method and Apparatus for the Detection of Impaired Dark Adaptation

ABSTRACT

The present method describes a new method for the measurement of dark adaptation. The dark adaptation status of subjects may then be used to identify those subjects who are at risk of developing and/or who are currently suffering from a variety of disease states having their clinical manifestations in impaired dark adaptation. The disease states include, but are not limited to, age related macular degeneration, vitamin A deficiency, Sorsby&#39;s Fundus Dystrophy, late autosomal dominant retinal degeneration, retinal impairment related to diabetes and diabetic retinopathy. An apparatus for administering the test method described is also provided.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. application Ser. No.13/028,893, filed Feb. 16, 2011 (currently published). U.S. applicationSer. No. 13/028,893 is a continuation of U.S. application Ser. No.12/886,264, filed Sep. 20, 2010 (abandoned). U.S. application Ser. No.12/886,264 is a continuation of U.S. application Ser. No. 12/391,829,filed Sep. 4, 2009, now U.S. Pat. No. 7,798,646, issued Sep. 21, 2010.U.S. Pat. No. 7,798,646 is a divisional of U.S. application Ser. No.10/571,230, filed Mar. 6, 2006, now U.S. Pat. No. 7,494,222, issued Feb.24, 2009. U.S. Pat. No. 7,494,222 is a national stage application ofinternational application no. PCT/US2004/29003, filed Sep. 3, 2004(expired). International application no. PCT/US2004/29003 claims thebenefit of U.S. Provisional Application No. 60/500,163, filed Sep. 4,2003 (expired).

FIELD OF THE DISCLOSURE

The present disclosure relates to methods and apparatus for thediagnosis of impaired dark adaptation and/or the identification ofindividuals who are at-risk of disease states related to impaired darkadaptation.

BACKGROUND

The macula of the human eye, which is about 6 mm in diameter and coversthe central 21.5 degrees of visual angle, is designed for detailedvision. The macula comprises a small cone-dominated fovea surrounded bya rod-dominated parafovea (Curcio 1990, J. Comp. Neurol. 292:497). Rodsare responsible for vision in dim light while cones are responsive tobright light and colors. In young adults, the number of rods outnumberscones by approximately 9:1. This proportion of rods to cones changes asindividual's age. The health and function of the rod and conephotoreceptors are maintained by the retinal pigment epithelium (RPE),the Bruch's membrane and the choriocapillaris (collectively referred toas the RPE/Bruch's membrane complex). The RPE is a dedicated layer ofnurse cells behind the neural retina. The RPE sustains photoreceptorhealth in a number of ways, including, but not limited to, maintainingproper ionic balance, transporting and filtering nutrients, providingretinoid intermediates to replenish photopigment bleached by lightexposure and absorbing stray photons. The RPE and the photoreceptors areseparated by the choriocapillaris, which provides blood flow to theneural retina. Further separating the RPE and the choriocapillaris isthe Bruch's membrane, a delicate vessel wall only 2-6 μm thick.

As the function of the RPE/Bruch's membrane complex is impaired, theresult is deficient nutrient and oxygen transport to the photoreceptorsand reduced clearance of by-products of bleaching, such as opsin.Therefore, as a result of the impairments of the function of theRPE/Bruch's membrane complex, the health and function of thephotoreceptors may be impaired. This is especially true with the rodphotoreceptors, which are responsible for scotopic, or dark-adaptedvision. The impairment of the rod photoreceptors may lead to impairmentin dark adaptation. Dark adaptation is defined as the recovery of lightsensitivity by the retina in the dark after exposure to a bright light.In this regard, dark adaptation can essentially be viewed as a bioassayof the health of the RPE, the Bruch's membrane and the choriocapillaris,and impaired dark adaptation may be used as a clinical marker of diseasestates that impair one or more of the RPE, the Bruch's membrane and thechoriocapillaris. Such disease states include, but are not limited toage-related macular degeneration (ARMD; which is also known asage-related maculopathy ARM), vitamin A deficiency, Sorsby's FundusDystrophy, late autosomal dominant retinal degeneration, retinalimpairment related to diabetes and diabetic retinopathy. Patients withARMD often have impaired dark adaptation as a result of thepathophysiology associated with ARMD. Dark adaptation may beparticularly useful in this regard since deficits in dark adaptationgenerally occur before clinical manifestations of the disease statebecome evident.

Currently ARMD is the leading cause of new, untreatable vision loss inthe elderly populations of the industrialized world (Mitchell 1995,Ophthalmology, 102:1450; Vingerling 1995, Ophthalmology, 102:205). Withthe increasing proportion of old adults in industrialized countries, theimpact of ARMD on health care costs will worsen (Council 1998, VisionResearch-A National plan 1999-2003; Executive Summary). ARMD is aheterogeneous disorder and is related to the breakdown of one or morecomponents of the RPE/Bruch's membrane complex. As discussed above,impairment of the RPE/Bruch's membrane complex can impact the health andfunctionality of the photoreceptors and lead to impaired darkadaptation.

Early to intermediate ARMD is characterized by minor to moderate visionloss associated with extracellular lesions, and changes in the RPEpigmentation and morphology. The lesions between the RPE and the Bruch'smembrane can be either focal (referred to as drusen) or diffuse(referred to as basal linear deposits). Advanced ARMD is characterizedby severe vision loss associated with extensive RPE atrophy with orwithout the squelea of choroidal neovascularization (which is thein-growth of choroidal vessels through the Bruch's membrane and underthe RPE in the plane of the drusen and/or the basal linear deposits). Inthe United States late stage ARMD accounts for 22% of monocularblindness and 75% of legal blindness in adults over the age of 50 (Klein1995, Opthamol. Vis. Sci. 36:182). It is currently believed that ARMD isa multi-factorial process involving a complex interplay of genetic andenvironmental factors. The principal treatment for late stage ARMD isphotocoagulation of the aberrant blood vessels comprising the choroidalneovascularization. However, only a subset of patients with existingneovascularization will qualify for such treatment.

A potential treatment approach is to prevent or delay the onset of latestage ARMD. For example, the Age-related Eye Disease Study (2002)indicated that the intake of several anti-oxidant compounds (such asbeta-carotene, vitamin C and vitamin E in conjunction with zinc andcopper) was beneficial in preventing neovascularization in intermediateARMD patients with drusen in both eyes, which places them at high riskfor developing advanced ARMD (AREDS report no. 8, 2001). A number oftherapeutics such as anecortave acetate (Retaane; Alcon Labs),pegaptabnib sodium (Macugen; Eyetech), ranibizumab (Lucentis; Genetech)and combretastatin (CA4P; Oxigene) are in various stages of development.Other treatment options under investigation range from brachytherapy torheopheresis, and observational studies have been examining possibleprotective roles for anti-inflammatory and lipid-lowering drugs.

However, these approaches require that patients at risk for ARMD orother disease states that impact the RPE/Bruch's membrane complex and/ordark adaptation be identified early enough so that preventive measurescan be undertaken. Furthermore, advising patients whether the risk andcost of a treatment is warranted requires the ability to monitor whethertheir disease progression is affected by their course of treatment. Sucha diagnostic method suitable for widespread, clinical use is currentlynot available in the art. The present disclosure provides such a methodto identify deficits in dark adaptation and describes an apparatuscapable of carrying out said method. Such deficits in dark adaptationmay be used to identify those at risk for developing disease states thatimpact the RPE/Bruch's membrane complex and/or dark adaptation andtracking the disease/treatment progression among those already affectedby the disease.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 is an exemplary dark adaptation curve illustrating the variouscomponents of dark adaptation.

FIG. 2 compares exemplary dark adaptation curves for a normal old adult(closed circles), an early-stage ARMD patient (open triangles) and alate-stage ARMD patient (open circles).

FIG. 3 is an illustration of the determination of the rod intercept darkadaptation parameter.

FIG. 4 shows the results of varying the intensity of the bleaching lightfrom a high intensity (open circles and squares) to a low intensity(closed circles and squares) on dark adaptation curves.

FIG. 5A shows a schematic of one embodiment of the apparatus of thepresent disclosure

FIG. 5B shows a schematic of one embodiment of the interior of theapparatus of the present disclosure as viewed by a subject.

FIG. 6 illustrates dark adaptation curves generated from a normalindividual (closed circle), an early ARMD patient (open square) anintermediate ARMD patient (open triangle) and a late ARMD patient (opendiamond) and shows that impaired dark adaptation can be used to predictARMD disease severity and/or progression.

DETAILED DESCRIPTION

The human macula comprises a small cone-dominated fovea surrounded by arod-dominated parafovea. The function of the rod and cone photoreceptorsis impacted by the health of the components of the RPE/Bruch's membranecomplex. As the function of the RPE/Bruch's membrane complex isimpaired, the result is deficient nutrient and oxygen transport to thephotoreceptors and reduced clearance of by-products of bleaching, suchas opsin. Therefore, as a result of the impairments of the function ofthe RPE/Bruch's membrane complex, the health and function of thephotoreceptors may be impaired. In many cases, the rod photoreceptorsare especially vulnerable. The rod photoreceptors are responsible forscotopic, or dark-adapted vision. The result of damage to the rodphotoreceptors is impaired dark adaptation in the subject. Therefore,impaired dark adaptation can be a surrogate marker for damage to theRPE/Bruch's membrane complex and may be used to diagnose individualswith disease states that have their clinical manifestations via theirimpact on the RPE/Bruch's membrane complex and/or to identify thoseindividuals who may be at risk for developing such disease states. Suchdisease states, include but are not limited to, ARMD, vitamin Adeficiency, Sorsby's Fundus Dystrophy, late autosomal dominant retinaldegeneration, retinal impairment related to diabetes and diabeticretinopathy. However, prior methods for determining impaired darkadaptation are cumbersome and time consuming to administer.

What the art is lacking is a method to determined impaired darkadaptation which is a sensitive and accurate indicator of those patientssuffering impaired dark adaptation, which produces high test-retestreliability and reproducibility, which can be administered in theclinical setting with decreased burden on the subject and the healthcareprovider, and which is simple to administer. The subjects identifiedwith impaired dark adaptation can then be evaluated for a variety ofdisease states, such as, but not limited to, those discussed herein. Forexample, patients with impaired dark adaptation can be monitored forincreased risk of ARMD. In addition, patients identified with ARMD canbe monitored to track ARMD disease progression, such as but not limitedto, the progression from early ARMD to intermediate ARMD or intermediateARMD to advanced/late ARMD. Furthermore, such individuals may be startedon early intervention strategies to prevent or delay the onset of ARMDand the effectiveness of such intervention strategies can be monitored.

The present disclosure describes a new method for the measurement ofrod-mediated dark adaptation to prospectively identify subjects who haveimpaired dark adaptation and who are at-risk for developing a variety ofdisease states, such as ARMD, and which meets limitations imposed by theclinical setting. The method can be administered in a short time (in aslittle as 20 minutes or less) in the clinical setting. As a result,healthcare providers will be able to offer the test on a practical andaffordable basis, making application of the test and realization of itsbenefits more widespread. In addition, the burden the test imposes onthe subject and the healthcare provider will be significantly reduced.Importantly, the method and apparatus described allows a broader rangeof subjects to be tested, for instance children or those with impairedcognitive ability. Furthermore, the subject need not have prior exposureto psychophysical test methods. An apparatus for administering such amethod is also described.

In addition to its use as a diagnostic tool, the method described hereincan be used to identify the structural, biochemical and physiologicalchanges responsible for the visual dysfunction associated with impaireddark adaptation and the progression of the disease states associatedwith impaired dark adaptation, such as, but not limited to, ARMD,vitamin A deficiency, Sorsby's Fundus Dystrophy, late autosomal dominantretinal degeneration, retinal impairment related to diabetes anddiabetic retinopathy. This is particularly useful since many of suchdisease states are currently believed to be a heterogeneous rather thana unitary genetic phenomenon and thus may have a variety of clinicalmanifestations depending on the underlying cause. By the early andaccurate identification of those individuals at risk for developing ARMDand the other disease states discussed herein (by virtue of theiridentification as having impaired dark adaptation) the structural,biochemical and physiological changes can be identified and correlatedwith various stages of disease state progression. Such information canbe used to design theoretical models of the disease state, evaluateanimal models of the disease state and to identify new opportunities fortherapeutic intervention in the treatment of the disease state.

The present disclosure presents ARMD as an exemplary disease state to bestudied using impairment of dark adaptation in a subject. However, themethod of determining such dark adaptation is applicable to the otherdisease states discussed herein and in any disease state that impactsone or more components of the RPE/Bruch's membrane complex.

The present disclosure shows that rod-mediated vision is more severelyaffected than cone-mediated vision in individuals at-risk for incidentARMD and in early ARMD patients. In addition, the impairment ofrod-mediated vision appears to precede the impairment of cone-mediatedvision. This relationship is significant since the most debilitatingvision impairment associated with ARMD is caused by the loss of conephotoreceptors. Therefore, by monitoring the health of therod-photoreceptors, which as discussed above is also indicative of thehealth of the RPE/Bruch's membrane complex, those individuals sufferingfrom or at-risk for ARMD, can be identified. This earlier detection willresult in the initiation of preventive measure, increased monitoringand/or early initiation of treatment before cone-photoreceptors areimpaired. As a result, the most significant aspect of ARMD-relatedvision impairment may be prevented or delayed.

Most ARMD patients exhibit more rod-mediated (scotopic) visualsensitivity loss than cone-mediated (photopic) visual sensitivity loss.Rod-mediated dark adaptation is especially susceptible to the effects ofARMD, as discussed in more detail below and many early ARMD patientsexhibit abnormal dark adaptation in the absence of other vision functionabnormalities such as reduced acuity, contrast sensitivity or visualsensitivity. Methods do exist for the diagnosis and detection of ARMD.However, these methods are insensitive in that they generally detectonly visible lesions associated with early ARMD (which indicates laterstages of disease progression), and are subject to a large degree ofclinical judgment, resulting in a range of interpretations of the testresults. Most of the tests are too sophisticated for the averagehealthcare provider to administer. In addition, the interpretation ofthe test results requires years of clinical experience and even then canbe subject to substantial variation. Current test methods also place asignificant burden on the patient and the healthcare provider. Nosuitable method is currently available for the detection of ARMD thatovercomes these obstacles. Even if the currently available tests areadministered, they still do not reliably identify patients at risk forARMD.

As an example, fundus photography and grading can be used to detectARMD. However, fundus photography is not capable of detectingmicroscopic lesions or the biological changes associated with ARMD.Anatomical and histopathological studies of donor eyes indicate that thepathological processes underlying ARMD, and the subsequent damage causedby these processes, are well underway before fundus photography candetect signs of ARMD. In addition, the test is relatively expensive,requires specialized equipment and training to administer and is subjectto variations in interpretation. Reliable interpretation of fundusphotographs is possible by utilizing a fundus reading center. However,the use of a fundus reading center for routine clinical use isimpractical because of the cost and turn around time of the results,which generally takes several months. As a result, fundus photographyhas not been widely used as a means to diagnose ARMD. As an additionalexample, flourosceine angiography is currently used as the method ofchoice for diagnosing late state ARMD. However, this method is invasiveas the flourosceine dye must be administered to the subject via the IVroute. In addition, reactions to the flourosceine dye occur forapproximately 1-1000 subjects. These reactions may be severe and mayeven be fatal in some cases. As a result, a physician is required to bein attendance during the procedure. Therefore, the burden on the subjectand the healthcare professional is quite high.

General Description of Test Parameters

A general description of the method and the parameters involved in themethod disclosed is given below. In the method described, darkadaptation is measured with a custom, computerized automatedadaptometer. The subject undergoing testing is subject to a bleachingprotocol. The bleaching protocol may be varied as is known in the art.The bleaching protocol adapts the test eye to a light of a firstluminance level (by desensitizing a portion of the rhodopsin moleculesin the test eye on exposure to the light of a first luminance level).Visual recovery (i.e. dark adaptation) is then measured as the test eyeadapts to a light of a second luminance level. Therefore, the firstluminance level serves as a standardized baseline from which visualrecovery is measured. Any bleaching protocol that provides thisstandardized baseline may be used in the method and apparatus describedherein. The first luminance level is brighter than the second luminancelevel, but the absolute intensity values of the first and secondluminance levels may be varied as desired. Generally, the greater theabsolute value of the first luminance level, the shorter the period ofexposure of the test eye to the light of the first luminance level toachieve the baseline. For example, the light of the first luminancelevel may be an intense light, such as that provided by an electronicstrobe or flash, and the light of the second luminance level may be ator close to 0 cd/m², such as would occur in a dark room. Alternatively,the light of the first luminance level may be a light produced by anordinary light bulb or by the ambient light in a room, and the light ofthe second luminance level may be at or close to 0 cd/m², such as wouldoccur in a dark room.

Many light delivery methods can be used to deliver the light of thefirst luminance level (which is referred to hereafter as a bleachinglight), such as photographic flashes, adapting fields, illuminatedbackgrounds, direct projection into the eye, exposure to ambient light,or staring into a light bulb. As discussed above, there are numerouspossibilities. Classically, subjects viewed an adapting field to bleachthe photopigment. This bleaching method causes discomfort to thesubject, and it is difficult to reliably deliver bleaches inpsychophysically inexperienced subjects. Another method of bleaching isto project light into the eye using a Maxwellian view system. Thismethod causes less irritation, but requires the subjects to fixate verysteadily and not blink for 30 to 60 seconds. Many inexperienced subjectsfind this to be a difficult task. If the subject changes fixation orblinks, it is necessary to wait up to 2 hours before the bleach isrepeated to avoid the cumulative effects of bleaching. Bleaching lightdelivered by an electronic strobe or flash delivers a high intensitylight in a short period of time. Because the light exposure is brief andcan be localized outside the fovea, it is not irritating to the subjectsand the subjects do not need to maintain fixation for long period oftime. With proper patient instructions blinking is not an issue.

The bleaching protocol desensitizes the desired amount of rhodopsinmolecules and provides a standardized baseline to measure visualrecovery to the second luminance level. The intensity of the bleachinglight or the time of exposure to the bleaching light can be modulated toproduce the desired amount of desensitization. In one embodiment, anequivalent of about 50% to 100% of the rhodopsin molecules isdesensitized. The bleaching light may be an achromatic camera flash. Theintensity of the bleaching light can be adjusted to desensitize theappropriate amount of rhodopsin molecules. For example, a bleachinglight intensity of 7.48 log scot Td/sec will bleach approximately 98% ofthe rhodopsin molecules, while a bleaching light intensity of 5.36 logscot Td/sec will bleach approximately 50% of the rhodopsin molecules.Alternate bleaching light intensities which desensitize less than 50% ormore than 50% of the rhodopsin molecules may also be used if desired.

After the bleaching protocol, visual recovery to the second luminancelevel is monitored. This recovery of light sensitivity is mediatedprimarily by the retina and measures predominately rod-mediatedsensitivity. The subject provides a series of responses to the targetstimulus (which is varied in intensity as described herein) which isused to generate one or more index factors. The index factors are usedin a comparison step to determine a dark adaptation status of thesubject. In one embodiment, the response of the subject is used todetermine a threshold measurement. During threshold measurements, thesubject is presented with a target stimulus. The target stimulus may bea spot of light, including a light spot on a darker background or a darkspot on a lighter background. Subjects may view the target stimulus withor without their best optical correction for the test distance. Avariety of classical methods can be used to determine the thresholdmeasurement, including but not limited to method of limits, justnoticeable difference, and method of adjustment. These techniques arewell known in the art. Thresholds measurements can be sampled in such away as to provide sufficient data to fit models of dark adaptation. Inone embodiment, threshold measurements are sampled once every 1 to 5minutes. Another embodiment would be to sample threshold measurementstwice every minute. Yet another embodiment would be to sample 2threshold measurements per minute early during the test then sample 1threshold measurement every 2 minutes thereafter. Higher or lowersampling rates may be used as desired to balance the need of producingan adequate dark adaptation function for model fitting against subjectburden. As an example of lower sampling rates, a small number ofthreshold measurements may be sampled based on predictions of rodphotoreceptor function in normal individuals. For example, a thresholdmeasurement may be obtained at 3-5 minutes (which in a normalindividuals would be before the rod-cone break) and at 5-10 minutes and10-15 minutes. If these threshold measurements do not correlate with therod photoreceptor function in normal individuals, the subject is likelyto have impaired dark adaptation. Such a sampling schedule would furtherreduce subject burden.

In one embodiment, a modified staircase threshold procedure may be usedto determine the threshold measurement. In one embodiment, a 3-down 1-upstaircase procedure is utilized. The “3-down” refers to the decrease inintensity of the target stimulus, while the “1-up” refers to theincrease in intensity of the target stimulus during selected portions ofthe threshold measurement. Variations in the decrease or increase in theintensity of the target stimulus may be used without altering the scopeof the present disclosure. An example illustrating the use of astaircase procedure is given below as an example. In the staircaseprocedure, the initial target stimulus intensity starts out at apredetermined intensity. In one embodiment, the initial target stimulusintensity is 4.85 cd/m², although other initial intensities may be used.The target stimulus is presented at predetermined time intervals. In oneembodiment the target stimulus is presented every 1-5 seconds, while inan alternate embodiment, target stimulus is presented every 2-3 seconds.The duration of the target stimulus presentation may also be varied. Inone embodiment, the target stimulus duration is about 100 to 400milliseconds, while in an alternate embodiment, the target stimulusduration is about 200 milliseconds. If the subject does not respond tothe target stimulus, the target stimulus intensity remains at theinitial intensity until the subject responds that the target stimulus isvisible. If the subject indicates the target stimulus is visible, thetarget stimulus intensity is decreased by a predetermined amount untilthe subject stops responding that the target stimulus is present. Forexample, in a 3-down 1-up staircase, the target stimulus intensity isdecreased by 3 “unit” increments, such as 0.3 log units, on successivemeasurements. After the subject responds that the target stimulus isinvisible (by failure to respond to the presence of the targetstimulus), the target stimulus intensity is increased by a predeterminedamount until the subject responded that the target stimulus is onceagain visible. For example, in a 3-down 1-up staircase, the targetstimulus intensity is increased by 1 “unit” increments, such as 0.1 logunits, on successive measurements. This target stimulus intensity atwhich the subject reports the target stimulus is again visible isdefined as the threshold and is recorded as the threshold measurement.The time and intensity level of the target stimulus are recorded (eithermanually or automatically by a means for control on the test apparatus).No threshold is recorded until the staircase is completed. Successivethreshold measurements are initiated with a target stimulus intensity apredetermined amount brighter than the previous determined thresholdmeasurement. For example, in a 3-down 1-up staircase, the targetstimulus intensity is increased by 3 “unit” increments, such as 0.3 logunits, for the next threshold measurement sequence. Alternatively, it ispossible to use a traditional staircase technique in which only thereversals are recorded, or to record all of the subject responses to thetarget stimulus (i.e.; all raw data inputs used to obtain thethresholds).The subject responses are recorded as well as the time theresponse was determined. The subject responses may be used directly inthe comparison step as discussed below. The subject responses may alsobe used to generate a plurality of threshold measurements as describedherein, and said threshold measurements used in the comparison step asdiscussed below. The subject responses may be used in conjunction withan appropriate dark adaptation model (either with or without generatingthreshold measurements) to generate one or more of the index factors andsaid index factors used in the comparison step as discussed below. Thesubject responses or threshold measurements may be subject to certainnoise reduction protocols to increase the quality of the thresholdmeasurements and to eliminate artifacts that may be due to subjectinattention or subject error. After processing for noise reduction, theresponses or threshold measurements may be used as described. The noisereduction protocols may be applied as the responses or thresholdmeasurements are generated, after all responses or measurements areacquired, or at any intermediate time point.

A variety of noise reduction protocols may be used. A preferredembodiment is non-destructive noise reduction, where outliers aredeleted without altering the retained data. This approach has theadvantage of preserving the absolute and relative information content ofthe threshold curve subject to noise reduction, as opposed to smoothingalgorithms or transformation functions that alter the informationcontent of the retained data. One such non-destructive noise reductionprotocol is termed “threshold guidance”. With threshold guidance, eachthreshold measurement obtained after the initial threshold measurement(referred to as a “presumptive threshold measurement”) is compared to atleast one preceding threshold measurement (referred to as the “basethreshold measurement”). For example, the tenth threshold measurementobtained (the presumptive threshold measurement) may be compared withthe ninth threshold measurement obtained (the base thresholdmeasurement). Alternatively, the tenth threshold measurement obtained(the presumptive threshold measurement) may be compared to more than onepreceding threshold measurement, such as the seventh through ninththreshold measurement (collectively, the base threshold measurement).Based on the physiological constraints of the adaptation of the retinabetween the first luminance level and the second luminance level and thetime between the base threshold measurement and the presumptivethreshold measurement, a maximum change in presumptive thresholdmeasurement can be estimated accurately using the base thresholdmeasurement. A range (referred to as the “window”)is established giventhe maximum change possible and this range is applied to the basethreshold measurement. The presumptive threshold measurement is thenexamined to determine if the presumptive threshold measurement fallswith the established window. If the presumptive threshold measurementfalls within the window, the presumptive threshold measurement isconsidered a valid threshold measurement and can be used as described.If the presumptive threshold measurement falls outside the window, thethreshold measurement is considered invalid and is not consideredfurther. In an alternate embodiment of threshold guidance, eachpresumptive threshold measurement is compared to a model fit of all or aportion of the base threshold measurement to determine whether thepresumptive threshold measurement falls within an established windowanchored to the model fit. For any embodiment of threshold guidance, theprocess may be automated by creating an algorithm that captures thedesired criteria and applying the algorithm to the thresholdmeasurements. Such an algorithm may be applied by the means for controlas described herein. The threshold guidance technique may be applied asthe threshold measurements are acquired or may be applied after all or aportion of the threshold measurements are acquired.

Another non-destructive noise reduction strategy is termed “curveguidance”. In curve guidance, the threshold measurements are filteredusing a statistical function of a defined width anchored to thethreshold measurements or a model fit of the threshold measurements. Anythreshold measurement that falls outside of the defined width isrejected and removed from further consideration. The filter can then bereapplied to the threshold measurements (either with the initial widthor a modified width). Again, any threshold measurement that fallsoutside of the width is rejected and removed from further consideration.This process can be repeated as desired in an iterative manner tofurther refine the threshold measurements. In one preferred embodiment,the statistical function is a band pass filter or its equivalent havinga width defined by a first statistical parameter of the thresholdfunction and anchored to a moving means function of the thresholdmeasurements. Other means of defining the filter width, such as cutpoints, limit functions or windows can be used. Other functions of thethreshold measurements, such as autoregressions and weighted movingaverages, can be used as the anchor. In another embodiment, thestatistical function defining the filter width can be anchored to amodel fit of dark adaptation applied to the threshold measurements.

Such noise reduction strategies will allow the unbiased examination ofthreshold measurements to determine their validity. As a result, invalidthreshold measurements caused by subject error or inattention can beremoved before the threshold measurements are applied to the appropriatedark adaptation model. This will widen the scope of subjects who can areeligible to undergo the described method and increase the reliabilityand reproducibility of the method described. The noise reductionstrategies described may be applied alone or in combination.

The target stimulus is of a spectrum of light that is effective inisolating the rod response (i.e., stimulating the rods with no or littlestimulation of the cones). A range of target stimulus wavelengths can beused to isolate the rod response. In one embodiment, the spectrum iscomprised of at least one wavelength in the range from 400 nm to 550 nm.In an alternate embodiment, the spectrum is comprised of at least onewavelength in the range from 400 nm to 500 nm. In yet another alternateembodiment, the spectrum has a single wavelength of 500 nm. (awavelength of light near the peak of rod photoreceptor sensitivity). Thetarget stimulus may cover about 1.5 to 7.0 degrees visual angle. In oneembodiment, the target stimulus covers about 2.0 to 3.0 degrees ofvisual angle. In yet another alternate embodiment, the target stimuluscovers about 2 degrees of visual angle. As the size of the targetstimulus increases to cover a wider degree of visual angle, thesensitivity of the test may decrease, but such increased target stimulussizes may be used if desired. The target stimulus may be presented at avariety of locations, so long as the target stimulus is placed in anarea where rod photoreceptors dominate. In one embodiment the targetstimulus is presented at a location from 20 degrees in the inferiorvisual field on the vertical meridian to 2 degrees in the inferiorvertical field on the meridian. In another embodiment, the targetstimulus is located in the macula. In an alternate embodiment, thetarget stimulus is located adjacent to the macula. In yet anotheralternate embodiment, the target stimulus is located in an area of themacula that is not on or overlapping the fovea, such as the parafovea.Positioning the target stimulus on or overlapping the fovea may decreasethe sensitivity of the method, but such locations may be used ifdesired.

The threshold measurements may be used to generate a full or a partialdark adaptation threshold function/curve. In such a thresholdfunction/curve, one or more threshold measurements (which indicatesensitivity of recovery) are plotted as a function of time to generatethe dark adaptation function/curve. Various scales for the sensitivitymeasurement may be used, such as a semi-log unit scale. The curve is notrequired to be generated, but may be helpful as a visual tool to aid thehealthcare provider.

The obtaining of thresholds measurements may be terminated based on adecision rule. A number of decision rules are possible. For example,threshold measurements may be terminated after defined period of timehas elapsed, when the subject's visual sensitivity ceases to change overa defined period of time or when the subject's sensitivity returns to apreviously obtained baseline value measured prior to bleaching.Additionally, threshold measurements may be terminated if a specificdark index factor, such as a adaptation parameter, does not appearwithin a defined period of time (for example, if the rod-cone break orthe rod intercept does not appear within said defined period of time),on the inability to fit the threshold measurements to an appropriatemodel of dark adaptation, or on the failure to make a sufficiently closematch to the comparative database (discussed below).

The threshold measurements obtained as discussed above may be directlycompared to the comparative database or may be applied to an appropriatedark adaptation model as discussed below. A variety of models may beused. These include models with one component or more than onecomponent. Examples of models that may used include, but are not limitedto, a one-linear, one-exponential model, a bi-linear model, and atri-linear model. In one example of a two-component model, one componentmodels the cone photoreceptors and one component models the rodphotoreceptors. When more than two components are used in the model, therods or the cones may be analyzed by the additional components of themodel. However, it is more common for the rods to be analyzed by theadditional components. In such a model, the cone photoreceptors, and thesecond and third rod components may all be analyzed with a linearfunction (a tri-linear model). The various components may use linear orexponential functions and may be fit using nonlinear regression or aleast squares fit. Other statistical methods may also be used. Darkadaptation parameters, individual threshold measurements or other datamay be extracted from the modeled data without providing a graphicalthreshold curve. Key dark adaptation function parameters that can beextracted from the model fit include, but are not limited to, therod-cone break time, the rod intercept and the rod recovery timeconstant.

In one preferred embodiment of a two component model, a linear functionis used to analyze the cone photoreceptors while an exponential functionis used to analyze the rod photoreceptors. In this model the linearcomponent represents the rapid, cone-mediated portion of the recoveryand the exponential recovery represents the slower, rod-mediated portionof the recovery. The point that connects these two components is definedas the rod-cone break, a parameter of interest in determining darkadaptation. The time constant of the exponential component is defined asthe rod time constant, an additional parameter of interest. Otherparameters may be analyzed as discussed below. This model has been shownto objectively estimate the rod-cone break and the time constant of rodsensitivity recovery. While it is known that the exponentialrod-mediated recovery is actually comprised of second and third rodcomponents, more detailed modeling does not necessarily result inimproved analysis of dark adaptation. However, the second and third rodcomponents may be analyzed by their own modeling components if desired.For some patients with late ARMD, this two-component model may notprovide a satisfactory fit because insufficient sensitivity recoveryafter the rod-cone break will cause the exponential portion of the modelto fit poorly. For example, FIG. 2 shows a comparison of dark adaptationcurves generated by the method disclosed from a normal subject (closedcircles), an early ARMD patient (open triangles) and a late ARMD patient(open circles). As can be seen, the rod mediated component of the curvegenerated from the late ARMD patient using the one-linear,one-exponential function would not provide a clear determination of therod-cone break. For cases such as these where the two-component modelproves inadequate (R²<0.9), a bilinear model may be applied to the datato accurately estimate rod-cone break, and the other parameters ofinterest. The flexibility of employing multiple models will allowtracking of disease progression further than strict adherence to asingle model.

The threshold measurements may be applied to an appropriate model fit asthe threshold measurements are generated, after all thresholdmeasurements are obtained or after a determined number of thresholdmeasurements are obtained. For example, every time a valid thresholdmeasurement is obtained, the threshold measurements may be applied to anappropriate dark adaptation model to determine if a threshold model fitcan be achieved. Using this approach, the model may be generatedinstantaneously as the test progresses. In addition, if a model fit isnot achieved in a predetermined amount of time (such as 5-10 minutes,the time point at which the rod-cone break should appear in a healthyindividual), the threshold measurements may be terminated and thesubject considered to have impaired dark adaptation. Alternatively, allthreshold measurements may be obtained before the threshold measurementsare applied to an appropriate model.

From the threshold measurements and the data generated during themodeling step, an “index factor” may be extracted. The index factor maybe a threshold curve generated by the appropriate model from thethreshold measurements, a partial threshold curve generated by theappropriate model from the threshold measurements, individual thresholdmeasurements selected from the appropriate model, individual thresholdmeasurements selected prior to modeling, a dark adaptation parameterdetermined from the appropriate model, or any combination of theforegoing. One or more index factors may then be compared withcorresponding index factors determined from healthy individuals todetermine the dark adaptation status of the subject.

The dark adaptation parameters include, but are not limited to, the timeconstant of the cone-mediated sensitivity recovery, the time constant ofrod-mediated sensitivity recovery, the cone plateau, the rod plateau,the rod-cone break, the rod intercept, the slope and/or time constant ofthe 2^(nd) component of the rod-mediated recovery, the slope and/or timeconstant of the 3^(rd) component of the rod-mediated recovery, thetransition time between the second and third rod-mediated components,and the duration from the bleaching to the final threshold measurement.

The dark adaptation parameters above are, with the exception of the rodintercept, described and known in the art and have the meanings known toone of ordinary skill in the art. The rod intercept is a novelparameter. In any test of dark adaptation, the cone photoreceptorscontribute to the recovery of dark adaptation. While the rod-cone breakis a sensitive indicator of dark adaptation impairment, the rod-conebreak is dependent, in part, on cone photoreceptor function. Thecontribution of the cone photoreceptors is not uniform betweenindividuals and impacts the timing of the rod-cone break. Thecontribution of the cone photoreceptors may also change over time, whichmay impact the data obtained over a period of time, such as might occurwhen monitoring a subject. It would be desirable to eliminate thecontribution of the cone photoreceptors (which may be referred to ascone contamination) to the dark adaptation parameters. The rod interceptaddresses this need. The rod intercept is the time at which the rodfunction would recover to (or “intercept”) a reference sensitivity levelin the absence of any cone function. Once the rod component of darkadaptation has been isolated or identified, an exponential model isfitted to the component. The rod intercept parameter is the time atwhich the exponential crosses the reference sensitivity value. Thesensitivity value can be any value, but is most useful when the value isgreater than the cone plateau. For purposes of example, the referencesensitivity level may be the zero sensitivity level, as this sensitivitylevel is above the cone plateau in all individuals. The rod interceptparameter is completely independent of the health and function of thecone photoreceptors and ideal for tracking the progression of darkadaptation impairment of the rods. An example of the rod intercept andits method of determination are given in FIG. 3. In this manner, the useof the rod intercept eliminates a confounding factor contributed by conephotoreceptor function and improves the sensitivity and specificity ofthe diagnosis of impaired dark adaptation.

The individuals in the comparative database may be aged matched to thesubject, or may be non-aged matched as compared to the subject. Forexample, if the subject is 65 years of age, in one embodiment thecomparative database may be composed of individuals with ages from 60 to70 years, or in a second embodiment, the comparative database may becomposed of individuals with ages from 25 to 40 years. The use of acomparative database comprising a younger population may offer certainadvantages since the younger subjects that comprise the population willbe more likely to be free of disease states and other conditions thatmay impact their dark adaptation. As discussed above, most priortechniques for diagnosing individuals with ARMD and other disease statesare not sensitive enough to detect individuals with early stages of thedisease states that can impact dark mediated adaptation. Therefore,using an age matched population for the comparison may actually decreasethe sensitivity of the method to identify impairments in dark mediatedadaptation since the age matched population of the comparative databasemay in fact have a certain degree of impaired dark adaptation.

The individuals making up the comparative database may be healthy (i.e.,disease free) or they may be selected based on their diagnosis with ARMDor any of the other disease states which have impaired dark adaptationas a clinical manifestation, or both. If healthy individuals areselected, the index factors determined from the subject can be comparedwith the corresponding index factors for the healthy individuals. Ifindividuals with a diagnosed disease state are selected, the indexfactors determined from the subject can be compared with thecorresponding index factors for the individuals diagnosed with a diseasestates and/or defined stages of a disease state. In this manner, thecomparison may be able to predict if the subject has impaired darkadaptation (from a comparison with healthy individuals in thecomparative database), is suffering from a disease state (from acomparison with individuals in the comparative database diagnosed withsaid disease state) or to diagnose the severity of the disease state(from a comparison with individuals in the comparative databasediagnosed with said stage of the disease state). For example, if thedisease state is ARMD, the index factors determined for the subject maybe compared to corresponding index factors from individuals in thecomparative database who are diagnosed with early, intermediate or latestage ARMD. The stratification of the database, as discussed below, mayaid in making such comparisons.

The comparative database may be stratified based on a number ofstratification criteria. These criteria may be dark adaptation status,risk factors, demographic factors, other relevant factors or acombination of the preceding. Examples, of risk factors include, but arenot limited to, age, smoking status, body mass index, and status withregard to health conditions (for example diabetes and ARMD status).Other risk factors may also be included. Demographic factors include,but are not limited to, lens density, gender and ethnicity. Theinclusion of a specific stratification criteria as a risk factor ordemographic factor may be modified (for example, age may be consideredboth a risk factor and a demographic factor). The individuals in thecomparative database may be tagged or otherwise identified, such thatthe appropriate population of individuals in the comparative databasemay be selected for the comparison to the subject.

Furthermore, the comparative database may be refined over time. Theindividuals in the database may be followed over time and their healthstatus monitored. If an individual no longer meets an inclusioncriterion for the comparative database, the individual may be removed.The inclusion criteria may be development of a disease state or impaireddark adaptation within a defined time period of the inclusion of theindividual in said comparative database. As one example, if anindividual who was diagnosed as healthy and included in the comparativedatabase as such develops a disease state or develops impaired darkadaptation within a time period (for example 5 years of theirinclusion), the individual may be removed from the comparative databasesince it is possible that the data obtained from said individual may betainted by early clinical manifestations of the disease state orimpaired dark adaptation. In this manner the quality of the comparativedatabase may be improved over time, resulting in a database withimproved sensitivity and specificity.

One or more of these index factors is then compared to the correspondingindex factors obtained from appropriately selected individuals in acomparative database. Appropriately selected means that the index factorfrom a defined group of individuals in the comparative database isselected for comparison to the index factor from the subject. Thedefined group may be all the individuals in the database or less thanall the individuals in the comparative database. The defined group maybe selected on the basis of stratification criteria as discussed above.The healthcare provider may select the defined group, with suchselection based on one or more defining characteristics of the subject.For example, if the subject is a 60 year old, non-smoking, Caucasianmale suspected of having ARMD, the stratification criteria may be usedto select the defined group from the comparative database for thecomparison step. In one embodiment, the defined group may be selected onthe basis of ethnicity (Caucasian), gender (male), health status(disease free or diagnosed with ARMD), and age (20-45 years of age).Furthermore, the comparison may be carried out multiple times for anygiven subject to various iterations of the comparative database. Forexample, given the same 60 year old, non-smoking, Caucasian male subjectsuspected of having ARMD, a second comparison could be made using adefined group from the database selected on the basis of gender (male)only, or selected to include all individuals in the comparativedatabase.

The comparison may be made to the absolute value of the appropriateindex factor or to a normal reference range of the appropriate indexfactor from the comparative database to determine a dark adaptationstatus of the subject. The normal reference range is a statistical rangeabout said index factor. In one embodiment, the statistical range is themean of the values for the selected index factor from the comparativedatabase ±two standard deviations of the mean; other statistical rangesmay also be used. If the index factor determined for the subjectsatisfies an “impairment criteria” the subjects is considered to have animpaired dark adaptation status. If the index factor determined for thesubject does not satisfy an “impairment criteria” the subjects is notconsidered to have an impaired dark adaptation status.

The impairment criteria may vary depending on the nature of the definedgroup selected from the comparative database for the comparison step. Ifa comparison is made to a defined group of healthy individuals from thecomparative database, the impairment criteria is satisfied if one ormore of the index factors determined for the subject fall outside of thenormal reference range for the corresponding index factors in thecomparative database. In this case, the subject is considered to have animpaired dark adaptation status and to be at risk for ARMD and the otherdisease states described herein. If a comparison is made to individualsfrom the comparative database having a diagnosed disease state and/or aspecific stage of a disease state, the impairment criteria is satisfiedif one or more of the index factors determined for the subject fallwithin the normal reference range for the corresponding index factors inthe comparative database. Again, the subject is considered to haveimpaired dark adaptation and to be at risk for ARMD and the otherdisease states described herein.

In addition, the method disclosed may incorporate certain “compensationstrategies”. These compensation strategies may be used to account forvariations in lens density, pupil size and other confounding factorsthat may impact the results of the method. For example, increased lensdensity may impact the results of the method since as lens densityincreases, less light passes through the lens to impact thephotoreceptors. One method to account for this factor is to determinethe lens density prior to implementing the method. One method ofdetermining lens density is laser inferometry. The lens is scanned witha laser as is known in the art and a determination of lens density ismade. This determination may be used to adjust the data prior to theanalysis or may be used to adjust one or more parameters of the methodprior to implementing the method, such as the intensity of the bleachinglight and the intensity of the target stimulus. In this manner, theparameters may be adjusted so as to provide the same intensity ofbleaching light and target stimulus to the photoreceptors of subjectswith altered lens density as to those subjects with normal lens density.As another example, pupil size may also impact the results of themethod. The pupils may be dilated prior to implementation of the methodso as to provide a standardized baseline for the test. Alternatively,the dilation step may be omitted and a mask or artificial pupil may beused to allow the bleaching light and target stimulus to interact with astandardized portion of the pupil.

Reference Test Method

An embodiment of the general test methodology will now be described. Themethod described in this section was used to generate the data describedin the Examples section below and the specification should not beconstrued as limited to the embodiment described below.

The target stimulus, in this case a spot of light, was presented to thesubject as a 500-nm, circular spot of light covering 1.7 degrees ofvisual angle. The target stimulus was presented at 12° in the inferiorvisual field on the vertical meridian, which is adjacent to the macula.The test eye was subject to a bleach (0.25 ms in duration) using anelectronic flash of achromatic light that produced a measured intensityof 7.65 log scotopic Trolands-sec, equivalent to inactivating ˜98% ofrhodopsin molecules in the test eye.

Threshold measurements were obtained immediately after flash offset. Thecontrol means on the test apparatus controls the psychophysicalprocedure and the parameters of the various steps and records thesubject's responses. In this embodiment, a 3-down 1-up modifiedstaircase threshold procedure was used to determine the thresholdmeasurement. The initial target stimulus intensity was 4.85 cd/m² andthe target stimulus was presented at 2-3 second time intervals for 200milliseconds duration. If the subject did not respond to the targetstimulus (indicating the target stimulus was visible), the targetstimulus intensity remained at 4.85 cd/m² until the subject responded.If the subject indicated the target stimulus was visible, the targetstimulus intensity was decreased by 0.3 log unit steps on successivethreshold measurements until the subject stopped responding that thetarget stimulus was present. After the subject responded that the targetstimulus was invisible (by failure to respond to the presence of thetarget stimulus), the target stimulus intensity was increased by 0.1 logunits until the subject responded that the target stimulus was onceagain visible. This target stimulus intensity was defined as thethreshold and the threshold measurement was recorded. No threshold wasrecorded until the staircase was completed. Successive thresholdmeasurements were initiated with a target stimulus intensity 0.3 logunits brighter than the previous determined threshold measurement.Successive threshold measurements were obtained as described above.Threshold estimates were obtained twice every minute for the first 25minutes and twice every 2 minutes thereafter until termination.Threshold measurements were terminated when the subject's thresholdmeasurements (which are an indication of rod sensitivity) were within0.3 log units of the subject's previously measured baseline sensitivity.

To interpret the dark adaptation data (i.e., the thresholdmeasurements), the thresholds were expressed as log sensitivity as afunction of time (minutes) after the bleaching. Each subject'srod-mediated function was fit using a nonlinear regression techniquewith a one-exponential, two-linear component model (McGwin, and Jackson1999, Behavior Research Methods, Instruments, and Computers 31: 712). Inthis embodiment, the index factors were the dark adaptation parametersdescribed above. One or more of these dark adaptation parameters wasthen compared to the reference ranges of the corresponding darkadaptation parameters obtained from an appropriately selected populationof healthy subjects in a comparative database. From this comparison, adetermination was made whether the subject's rod mediated darkadaptation process was impaired (i.e.; outside the reference range). Adetermination that a subject's rod-mediated dark adaptation was impairedsuggests that the individual is at-risk for ARMD or is suffering fromARMD.

The decision rule for determining whether a dark adaptation parameter isabnormal was based on comparison of the subject's dark adaptationparameter(s) to corresponding dark adaptation parameters in awell-defined comparative database. In the Examples below, thecomparative database was composed of adults of normal retinal health inthe age range of 20 years old to 45 years old. The comparison was madeto the reference range of the comparative database for the selected darkadaptation parameter. The reference range was the mean of the values forthe selected dark adaptation parameter from the comparative database±two standard deviations of the mean. If the subject's dark adaptationparameter fell outside the reference range for the corresponding darkadaptation parameter from the comparative database, dark adaptation isconsidered impaired and the subject is considered to be at-risk forARMD. If several dark adaptation parameters were estimated, and any onethe subject's determined dark adaptation parameters fell outside thereference range for the corresponding dark adaptation parameter from thecomparative database for any single parameter, dark adaptation isconsidered impaired and the subject is considered to be at-risk forARMD.

Optimization of Test Parameters

As previously discussed, one drawback to the current methods foranalyzing dark adaptation impairment is the length of times the currentmethods require. Current methodologies may require 90 minutes or morefor completion. Using the methods of the current disclosure,determination of dark adaptation impairment may be determined in lessthan 20 minutes. At least two variables influence the time taken toanalyze dark adaptation impairment: 1) the intensity of the bleachinglight; 2) and the location at which the target stimulus is presented.The lower the bleaching light intensity, the faster scotopic sensitivitywill recover. Similarly, moving the location at which the targetstimulus is presented into the macula from just outside the macula willshorten the time to recovery in normal patients.

Previous studies indicated that weaker bleaching protocols may provideless sensitive results for dark adaptation studies. However,surprisingly, a weaker bleaching protocol using a desensitizing flash of5.36 log scot Td/sec decreased the time required to determine therod-cone break and increased the ability to discriminate between earlyARMD subjects and normal adults. In one study, dark adaptation curveswere generated from an early ARMD subject and a subject with normalretinal health (using the reference test method described above) usingidentical parameters, with the exception that the intensity of thebleaching flash was varied between 7.48 log scot Td/sec (high intensitybleaching procedure, inactivating approximately 98% of the rhodopsinmolecules) and 5.36 log scot Td/sec (low intensity bleaching procedure,inactivating approximately 50% of the rhodopsin molecules). Darkadaptation curves were generated as described herein and the rod-conebreak and rod time constant dark adaptation parameters were analyzed foreach patient under each condition. The results of the study are shown inTable 1 and FIG. 4.

Table 1 shows that the time to the rod-cone break was shortened by morethan 8 minutes for both the normal subject and the early ARMD subject(to under 14 minutes in both cases). For the normal subject, the time toreach the rod-cone break using the high intensity bleaching protocol was15.41 minutes, while the time to reach the rod-cone break in the earlyARMD subject was 23.42 minutes. Using the low intensity bleachingprocedure, the times were reduced to 7.15 minutes and 13.56 minutes,respectively. Despite the decreased timescale to determine the rod-conebreak parameter, the ability to discriminate between those with earlyARMD and normal subjects was increased using the low intensity bleachingprocedure. As shown in table 1, using the high intensity bleachingprocedure the early ARMD patient showed a 52% impairment. In contrast,when the low intensity bleaching procedure was used, the early ARMDpatient showed a 90% impairment. Furthermore, the subjects exhibitedwell defined dark adaptation functions in response to the low intensitybleaching procedure. Such well defined dark adaptation functions with aprominent rod-cone break parameter aid in the analysis of the data andenhance repeatability and ease of use. FIG. 4 shows that the darkadaptation curves generated using the different bleaching parameters. InFIG. 4, the squares represent a 66-year-old normal adult while thecircles represent a 79-year-old ARMD patient. The closed circles andsquare indicate the low intensity bleaching procedure was used, whilethe open circles and squares indicate the high intensity bleachingprotocol was used. As can be seen, the low intensity bleaching procedureresulted in a quicker dark adaptation response, which as discussedabove, actually increased the sensitivity of the discrimination betweenthose subjects with early ARMD and those subjects with normal retinalhealth.

The impact of changing the location at which the target stimulus ispresented was also evaluated. The standard research protocol describedabove tests dark adaptation with the target stimulus presented at 12° inthe inferior visual field on the vertical meridian, corresponding to aperipheral location just adjacent to the macula. Because ARMD-relatedimpairment of the rod photoreceptors is greatest near the fovea anddecreases as a function of eccentricity towards the peripheral retina,testing dark adaptation at a more central location within the foveashould exhibit greater impairment than at a peripheral location. Darkadaptation curves were measured for a cohort of 10 ARMD patients (mean73 years old) and a cohort of 11 normal old adults (mean 70 years old).Each subject's dark adaptation was measured twice: once using a targetstimulus presented at 12° on the inferior vertical meridian and oneusing a target stimulus presented at 5° on the inferior verticalmeridian. All other test parameters were unchanged from the referencemethod described above. The two measurements were counterbalanced andconducted on separate days to avoid practice effects or carryovereffects. Several dark adaptation parameters generated from the darkadaptation curves using the two-component dark adaptation model arelisted in Table 2.

As can be seen in Table 2, the times to rod-cone break changed inopposite directions for the two cohorts. It decreased (as expected) by0.78 minutes for the normal old adults, but increased by 3.55 minutesfor the ARMD patients. These opposing shifts further increased theability to discriminate ARMD patients from normal old adults.Specifically, the ARMD cohort showed a 31% dark adaptation impairmentrelative to the normal old adults when the target stimulus was presentedat 12° on the inferior vertical meridian (20.48 minute rod-cone breakvs. 15.61 minutes for normal old adults), but the impairment increasedto 62% when the target stimulus was presented at the more central 5°inferior field location (20.48 minute rod-cone break vs. 15.61 minutesfor the normal old adults).

These modifications may be incorporated into the method described aboveto further decrease the time to implement the method and to furtherincrease the ability of the method to discriminate between patients withimpaired dark adaptation and those patients with normal dark adaptation.

General Description of Test Apparatus

The exact form and nature of the apparatus for conducting the methoddescribed herein may vary, as would be known to one of ordinary skill inthe art. An exemplary arrangement of an apparatus capable of applyingthe method described herein is provided below. The apparatus may bemodified and altered as would be obvious to one of ordinary skill in theart without deviating from the teachings disclosed herein.

In its most basic form, the apparatus comprises a means for generating atarget stimulus, means for displaying a target stimulus (which is usedto measure the recovery of visual sensitivity) and a means for input toallow the subject to convey to the healthcare provider informationregarding the target stimulus (such as that the target stimulus isvisible or the target stimulus is not visible). Other functions may beincorporated into the apparatus, such as a means for bleaching the testeye, a means for aligning the test eye, a means for confirming alignmentand similar items. In one embodiment, the means for displaying may be anoptical system. In such embodiment, a light source produces a light thatis acted on by one or more optical elements to produce the targetstimulus and project the target stimulus onto a screen or other displayor through a diffuser for visualization by the subject. In an alternateembodiment, the means for displaying may be an electronic system. Insuch embodiment, the target stimulus is produced by an electronic meansand is displayed on a CRT display, a liquid crystal display, a plasmadisplay or an LED display for visualization by the subject. Each ofthese embodiments is described below.

In the embodiment where the means for generating is an optical system,the optical system comprises the elements to generate and act on thetarget stimulus such that the target stimulus has the desiredcharacteristics. The means for generating comprises at least one of alight source, one or more optical elements and a screen or otherdisplay. The light source will be used to generate a light beam whichwill become the target stimulus, referred to as the target spot. Theremay be multiple or single light sources to generate the light beam. Inone embodiment, the light source is a bank of light emitting-diodes(LEDs). The light source may also be a tungsten lamp or any otherappropriate light source. The light source may emit white light and thelight beam (in this case white light) produced may be acted upon byvarious optical elements to produce a light beam of a desired spectrum,or there may be multiple light sources to generate light of variouswavelengths directly such that the light beam has a particular spectrumof wavelengths determined by the light emitted from the selected lightsource. Such light sources could be placed on a means for rotation sothat the appropriate light source could be selected as desired.

The light beam generated by the light source may be acted upon by aseries of optical elements to produce the target spot. A variety ofoptical elements may be used in various combinations to determine theproperties of the light beam. These include directing means to directthe light beam, refining means to collimate and shape the light beam,selecting means to select the desired spectrum of the light beam, andmodulating means to control the intensity of the light beam. In oneembodiment, the directing means are mirrors, the refining means isshaping optics, the selecting means is an optical filter, and themodulating means is a neutral density filter or an electronic modulator.Additional optical elements may also be incorporated, such as an opticalsplitter to direct a portion of the light beam to a calibration detectorto record the characteristics of the light beam and to ensure thecharacteristics of the light beam are as desired. The target spot isthen directed to a means for display, which may be a screen or othervisual display.

In the alternative, the means for generating may be electronic innature. The target stimulus may be generated by electronic rather thanoptical means as described above. In this embodiment the target stimulusis generated electronically. The electronics produce the appropriatewavelength of light for the target stimulus. Alternatively, a filter maybe inserted over the CRT display, the liquid crystal display, the plasmadisplay or an LED display, or other appropriate display to impart to thetarget stimulus the appropriate wavelength. The target stimulus is thendisplayed on a means for display, which may be a CRT or LED screen, orother appropriate display.

The apparatus may be portable or fixed in a permanent location. In oneembodiment, the subject may be confined in a testing booth and theapparatus may be a part of the testing booth or placed in the testingbooth. The healthcare provider may be located outside the testing boothto supervise the operation of the apparatus. An advantage of thisembodiment is that the healthcare provider will be in normal lightduring the implementation of the method and can better monitor themethod.

Exemplary Test Apparatus

One embodiment of the apparatus is shown in FIGS. 5A and 5B. Thisembodiment illustrates the means for generating as an optical system.The apparatus 1 comprises a housing 10 having a front side 12 and a rearside 14 joined by side walls and bottom and top walls. The housing 10has a viewing opening 50 to receive the head of the subject and allowthe subject to view the display means, such as screen 34. The viewingopening 50 may be adapted to eliminate or reduce ambient light fromentering the viewing opening and apparatus. The housing 10 is adaptedwith means for alignment to align the subject eye of the subject asdesired. In one embodiment, the means for alignment comprises a chinrest52 to receive the chin of the subject. The chinrest 52 is adjustable toaid in the alignment of the subject's eyes with the target spot 16 (asdiscussed below). The housing 10 also contains a headrest 54A and 54B tosupport the subject's forehead while using the machine. Headrests 54Aand 54B are selected for use depending on which eye of the subject isbeing tested.

The housing 10 contains the basic components of the apparatus. Ableaching light source 40 is provided within the housing 10 to generatethe bleaching light 42. The function of the bleaching light source 40 isas discussed above. The bleaching light source 40 may be adjusted toprovide a high intensity or a low intensity bleach. Alternatively, theapparatus 1 may omit the bleaching light source 40 and the bleachingstep carried out independently of the apparatus.

In the embodiment illustrated in FIG. 5A, the light source is a bank ofLEDs 20 which emit a white light beam 3 and an optical element acts onthe emitted white light beam 3 so that the target spot 16 is of thedesired spectrum. The use of LEDs 20 as the light source may provideseveral advantages. First, LEDs are exceeding robust, generate almost noheat load, require little or no safety hazard protection, and are verylow-cost. In addition, LEDs provide an opportunity for fine-scaleintensity control via electronics, eliminating the complexity andexpense of fine-scale control via neutral density wedges and othermethods.

The light beam 3 is acted upon by one or more optical elements. Theseoptical elements include, but are not limited to, directing means todirect the light beam, refining means to collimate and shape the lightbeam, selecting means to select the desired spectrum of the light beam,and modulating means to control the intensity of the light beam. In oneembodiment, the directing means are mirrors, the refining means areshaping optics, the selecting means is an optical filter, and themodulating means is a neutral density filter or an electronic modulator.The light beam 3 is acted upon by a first mirror 24 to direct the lightbeam 3 to the shaping optics 25. The shaping optics 25 collimates andshapes the light beam 3 so that the target spot 16 produced is of thedesired size and shape. The operation of such shaping optics 25 is wellknown in the art and is not discussed further herein. As the light beam3 emerges from the shaping optics 25 it passes through an optical filter26 so that the appropriate spectrum of light is selected for productionof the target spot 16. The optical filter 26 may be a color filter. Theoperation of such optical filters 26 is well known in the art and is notdiscussed further herein. As the light beam 3 emerges from the opticalfilter 26, it passes through an optical splitter 30. The opticalsplitter 30 directs a portion of the light to a calibration detector 32.The calibration detector 32 records the characteristics of the lightbeam 3 (such as, but not limited to, the spectrum and intensity) andpasses a portion of the light beam 3 further along the light path of theinstrument. The calibration detector 32 may be a photodiode calibrationdetector or other calibration detector as is known in the art. As thelight beam 3 emerges from the optical splitter 30, it is acted on byneutral density filter 28. The neutral density filter 28 modulates thebeam of light 3 to produce the desired intensity. The use of the neutraldensity filter 28 will allow control of the intensity of the light beam3 over six logs of dynamic range, with a maximum projected intensity of˜5 cd m⁻². As the light emerges from the neutral density filter 28, itis further directed by one or more mirrors 24 and is ultimatelyprojected as the target spot 16 onto a screen or other display. Thelocation of the target spot can be located at the desired area of thesubject's eye as discussed above. The directing means may be adjusted toachieve such localization. In the embodiment illustrated, the display isa screen 34. The display can be visualized by the subject.

A means for control is in communication with the various components ofthe apparatus 1, such as, but not limited to, the bleaching lightsource, the light source, the directing means, the refining means, theselecting means, and the modulating means. In addition, the means forcontrol may be in communication with the calibration detector and thesubject input means (as described below). For example, the control meansmay control the light emission from the light source so that the pulsesof light emitted by the light source correspond to the configurationrequired by the test method and emissions from the bleaching lightsource to ensure that the percent bleaching desired is obtained. Inaddition, the control means could adjust the refining means, theselecting means and the modulating means to produce a light beam withthe desired characteristics. Furthermore, the control means may adjustthe directing means to provide desired localization of the target spot.Therefore, the means for control is capable of adjusting the parametersof the components of the apparatus as dictated by the method described.Furthermore, the control means also records the status and output ofeach of the components of the apparatus. For example, the control meansmay record the intensity of the target stimulus. The control means alsorecords the input from the subject input means, which is used to allowthe subject to input his/her responses to the target stimulus, for usein generating the threshold values. The control means may furthermeasure and record the time elapsed during the implementation of themethod (said timing to start in one embodiment immediately after thebleaching step is accomplished) and the time at which subject inputs arereceived from the subject input means and the time at which the variousparameters of the method are changed (such as the changing intensity ofthe target stimulus). By comparing the timing of the subject response tothe target stimulus as received from the subject input means andcorrelating said subject responses to the status of the parameters ofthe apparatus, the control means may then determine and record thethreshold measurements and execute calculations required for noisereduction in the threshold measurements.

A means for comparison may be in communication with the means forcontrol. The means for comparison may be separate from or integral withthe means for control. The means for comparison may use the thresholdmeasurements and the information from the components of the system forsubsequent analysis. The means for comparison may be capable ofexecuting calculations to fit the threshold measurements to a desiredmodel of dark adaptation (such as, but not limited to, the one-linear,one-exponential model described above) and generating a full or partialdark adaptation model fit and/or the desired index factors from saidthreshold measurements and then recording and storing said information.As discussed above, the means for comparison may execute suchcalculations as the threshold measurements are collected, or may executesuch calculations after all desired threshold measurements are obtained.The means for comparison may be an external device in communication withthe control means via the internet.

The desired index factors may then be compared to corresponding indexfactors in a comparative database and the result recorded and stored.The comparative database index factors and comparison results may becontained within the means for comparison allowing the process to beautomated or may be separate from and in communication with the meansfor comparison. The means for comparison may output the information to avisual display as desired. The output may be in the form of a full orpartial threshold curve and dark adaptation model fit or other graphicalformat. In addition, the individual index factors may be displayed aswell. The output may be further conveyed to a storage device or anoutput device, such as a printer.

The configuration of the embodiment described in FIG. 5 is forillustrative purposes only. Other configurations containing additionalelements or similar substitutions for the elements described may beenvisioned. In addition, the order of the elements described may bere-arranged as desired.

The apparatus 1 may also contain a means for confirming alignment of thesubjects test eye. In one embodiment, such a means is an infrared camerawhich can be used to verify that the subject's test eye is properlyaligned to view the target spot 16 and the photobleaching light 42. Toaid the subject in achieving such alignment, a target fixation light 17and a bleaching fixation light 43 may be provided (see FIG. 5B). As thesubject fixes the test eye on the bleaching fixation light 43, thesubject can be assured the test eye is in the proper position to receivethe desired photobleaching effect. Likewise, as the subject fixes thetest eye on the target fixation light 17, the subject can be assured thetest eye is in the proper position to view the target spot 16. Thetarget fixation light 17 and the bleaching fixation light 43 may beproduced by additional light sources, such as LEDs incorporated at thedesired locations inside the apparatus or may be projected onto thescreen 34.

This design of the apparatus 1 will allow investigation of a broad rangeof target stimulus parameters by simple adjustment or change-out of themirrors, shaping optics and color filters. The target spot size,location and spectrum therefore can be varied as desired by thehealthcare provider. Furthermore, the intensity of the bleaching lightsource can also be controlled

Overview of Method Implementation

The use of the apparatus 1 to employ the method of the presentdisclosure will now be discussed. The operation of the apparatus andexecution of the method can be viewed as having 5 steps: 1) aligning thesubject; 2), photobleaching of the test eye; 3) monitoring recovery ofvisual sensitivity (i.e. scotopic recovery); 4) optionally fitting thedata obtained to an appropriate model to generate the dark adaptationparameters; and 5) comparing the threshold measurements or optionallythe the index factors, such as the dark adaptation parameters, from thesubject to a comparative database. The steps should not be construed aslimiting descriptions, but are simply convenient areas for furtherdetailed discussion. Each of these steps will be discussed in greaterdetail below. Furthermore, the hardware required to carry out each ofthese steps need not be incorporated into the test apparatus, but may beif desired.

In the alignment process, the subject is aligned by adjustment of thechin rest 52 vertically, horizontally or both vertically andhorizontally. Correct positioning of the subject is achieved by viewingthe subject's test eye with an infrared camera 70 mounted inside thehousing 10 while the subject focuses on the target fixation light 17.The optical system is arranged such that this single step aligns thesubject correctly with respect to both the bleaching light 42 and thetarget spot 16. The infrared camera 70 can be used as needed to confirmcontinued alignment of the subject. FIG. 5B shows a view of oneembodiment of the interior of the housing 10 as viewed through opening50 and represents the view a subject would encounter on using thedevice.

Once alignment of the subject is achieved, the subject's test eye issubject to a bleaching protocol by exposure to the bleaching light 42.In this embodiment, the bleaching light 42 is a brief, high intensitycamera flash or electronic strobe (typically 5 to 8 log scot Td/sec for0.25 ms) that is generated while the subject is focused on the bleachingfixation light 43 to ensure the proper portion of the rhodopsinmolecules of the retina is bleached. The amount of bleaching producedcan be determined by the healthcare provider by varying the desiredintensity of the bleaching light 42, which is controlled by the meansfor control as discussed above. In one embodiment, 50% to 98% of therhodopsin molecules are bleached.

The dark adaptation measurements begin immediately after the bleachingprotocol is administered by obtaining a series of thresholdmeasurements. With the subject once again focusing on the targetfixation light 17, the threshold measurements are obtained. In oneembodiment, the threshold measurements are obtained using a 3-down/1-upmodified staircase procedure. Starting at a first intensity (such as4.85 cd m⁻²), target spots 16 are presented on the screen 34 to thesubject every 2 to 3 sec for a defined duration (such as a 200 mspulse). If the subject does not respond to the target spot 16 (such asby activating the input means), the light intensity of the target spot16 remains unchanged until the subject responds. If the subjectindicates the target spot 16 is visible (such as by activating the inputmeans), the light intensity of the target spot 16 is decreased for eachsuccessive pulse in 0.3 log units (“3-down”) until the subject stopsresponding that the target spot 16 is present. After the subjectindicates that the target spot 16 is invisible, the light intensity ofthe target spot 16 is increased for each successive pulse in steps of0.1 log units (“1-up”) until the subject responds that the target spot16 is once again visible. This light intensity of the target spot 16 atthe completion of this sequence is defined as the threshold measurement.Successive threshold measurements start with a target spot 16 lightintensity 0.3 log units brighter than the previous thresholdmeasurement. Threshold measurements are made once or twice every minutefor the duration of the measurement protocol. During this process, thethreshold measurements are subjected to a noise reduction protocol asdiscussed above. Other implementations of the staircase protocol mayalso be used as described above and methods other than a staircaseprocedure may also be employed as would be known to one of skill in theart.

To focus on rod-mediated function, a target stimulus 16 with awavelength near the peak rod sensitivity (˜500 nm) is used. Correctivelenses can be introduced between the test eye and the target spot 16 asappropriate by means of a lens holder inside the machine (not shown).The duration of the measurement protocol can be varied and may beterminated in accordance with the decision rules as discussed above.

In one embodiment, the threshold measurements are then fit to a desiredmodel of dark adaptation. The desired model may be used to generate oneor more index factors. As discussed above, the index factors may be aplurality of threshold measurements, a full or partial threshold curveor a dark adaptation parameter. Any of the dark adaptation modelsdescribed herein or known to those of skill in the art may be used, suchas the two-component, one-linear one-exponential model. As previouslydescribed, the initial cone-mediated (photopic) portion of the thresholdcurve is modeled with a linear component, and the subsequentrod-mediated (scotopic) portion of the curve is modeled with anexponential component. The comparison means may be programmed to recordthe appropriate parameters, to fit the data to the desired model and toautomatically extract such index factors from the model. For somesubjects with late ARMD, this two-component model may not provide asatisfactory fit. Insufficient sensitivity recovery after the rod-conebreak will cause the exponential portion of the model to fit poorly. Forcases where the two-component model proves inadequate (R²<0.9), abilinear fit can be applied to the data to accurately estimate thedesired dark adaptation parameters, such as the rod-cone break, and theslope of the rod recovery will be recorded. The flexibility of employingmultiple models allows tracking of disease progression more accuratelythan strict adherence to a single model. Alternatively, the thresholdmeasurements may be output to the healthcare provider (in the form of apartial or full threshold curve, a dark adaptation model fit or tabledescribing the index factors) and the healthcare provider may extractthe dark adaptation parameters manually.

After the desired index factors are determined, one or more of thesubject's index factors are compared to the corresponding index factorsfrom individuals in a comparative database. In one embodiment, thesubject's dark adaptation parameters are compared to a reference rangeof the corresponding parameters in the comparative database. Thereference range may be a statistical parameter above and below the indexfactor in the comparative database, such as the mean of the selectedindex factor in the comparative database±two standard deviations of themean. If the subject's dark adaptation parameter falls outside thereference range, dark adaptation is considered impaired and the subjectis considered to be at risk for ARMD or other disease states asdescribed herein. If several index factors are estimated and the subjectis considered abnormal on any one of the estimated index factors, darkadaptation is considered impaired and the subject is considered to be atrisk for ARMD or other disease states as described herein. Thecomparative database is as described above. Alternatively, the thresholdmeasurements may be directly compared to corresponding thresholdmeasurements in the comparative database to determine dark adaptationstatus or disease state without going through the intermediate model fitand index factor determination.

CONCLUSION

In summary, determination of dark adaptation performed by the methodsdescribed above was shown to be a sensitive indicator of the earlieststages of ARMD. Therefore, dark adaptation can be used to identify thoseindividuals are at-risk for ARMD and the other disease states describedherein or any other disease states that impact rod photoreceptorfunction. Furthermore, dark adaptation can be used to indicate diseasestate severity and/or progression.

Given the disclosure herein, one of ordinary skill in the art may becomeaware of various other modifications, features, or improvements. Suchother modifications, features and improvements should be considered partof this disclosure. The cited references are incorporated by reference.

EXAMPLES Example 1

Using the reference method of the present disclosure, it was shown thatimpaired rod-mediated dark adaptation accurately predicts ARMD and is anearly functional marker of AMD. Twenty patients (65 to 79 years old)were examined who at baseline had normal retinal health. Normal retinalhealth was based on a grading of photographed fundus appearance usingthe standardized International Classification System. During the initialbaseline visit, rod-mediated dark adaptation was measured using themethod described herein. The patients were classified as having normalor impaired dark adaptation at the baseline visit. Impaired darkadaptation was defined using the rod-cone break parameter as the darkadaptation parameter, with impaired dark adaptation being diagnosed whenthe rod-cone break parameter fell outside the reference range (±2standard deviation of the mean) of normal healthy subjects in ourcomparative database. Eye health status was measured in the subsequent 4years after the baseline visit. Medical records were examined forchanges in the patient's retinal health. At the end of 4 years, 86% (12/14) of patients with impaired dark adaptation at baseline received adiagnosis of ARMD, whereas less than 17% (⅙) of patients with normaldark adaptation at baseline received a diagnosis of ARMD. These findingsindicate that impaired rod-mediated dark adaptation is a risk factor forARMD and that a method that accurately identifies impaired rod-mediateddark adaptation can be used to identify those individuals who are atrisk for incident early ARMD.

Example 2

Furthermore, rod-mediated dark adaptation kinetics are markedly slowedin early ARMD patients as compared to normal age-matched subjects. Darkadaptation parameters were obtained from 20 early ARMD patients (ages66-88) and 16 healthy subjects (ages 62-79) as described in the presentdisclosure. ARMD status was assigned using a standardized fundusphotography grading system. On average, the time constant ofrod-mediated sensitivity recovery of dark adaptation was markedly slowedin ARMD patients. In this study, the time to complete the test was onaverage 16 minutes longer for ARMD patients as compared to healthyindividuals. Further analysis of the data revealed that 85% of the ARMDpatients exhibited impaired rod-mediated dark adaptation as defined byat least one dark adaptation parameter falling outside ±2 standarddeviations of the mean normal value (see Table 3). In contrast, only 20%of the healthy subjects were classified as exhibiting impairedrod-mediated dark adaptation. Significantly, cone-mediated visualsensitivity, visual acuity and contrast sensitivity were classified asimpaired in only 25% of the ARMD patients, indicating impairedrod-mediated dark adaptation is a more sensitive indicator of early ARMDthan visual sensitivity, visual acuity and contrast sensitivity.

Example 3

In addition to identifying those individuals at risk for ARMD, themethod described herein may also be used to detect and determinedifferences in ARMD disease severity. Fundus photographs for a subset ofARMD patients and normal patients were sent to the Wisconsin ReadingCenter for grading in accordance with the Wisconsin Aging-RelatedMaculopathy Grading System (WARMDGS). Based on the results of the fundusphotography grading, three ARMD patients (open square, triangle anddiamond) and one normal patient (closed circle) were selected forexamination using the method described herein. The three ARMD patientsdisplayed different stages of ARMD progress. Patient no. 1 (open square)and no. 2 (open triangle) exhibited soft indistinct drusen with amaximum size of about 250 μm and a coverage area of about 1500 μm.However, patient no. 2 had 2-times the number of soft drusen withdistribution further away from the fovea, indicating a progression ofARMD disease. Patient no. 3 (open diamond) had a number of hard drusenand a pigment epithelial detachment, indicating an additionalprogression of ARMD disease over patients no. 1 and no. 2. The curvesand selected dark adaptation parameters generated from the thresholdmeasurements for patients 1-3 and the normal patient were then compared.As can be seen from FIG. 6, the times for rod-mediated sensitivityrecovery of dark adaptation for patient nos. 1-3 was significantlygreater than the normal control. Furthermore, the time required forrod-mediated sensitivity recovery of dark adaptation was greater as theARMD disease severity increased (with time increasing from patient no. 1to patient no. 3). This study indicates that impaired rod-mediated darkadaptation can be used not only to determine individuals at-risk forARMD, but to gauge ARMD disease severity and/or progression.

TABLE 1 Dark adaptation parameter differences for high bleach intensityvs. low bleach intensity High Bleach Intensity Low Bleach Intensity(~98% bleach) (~50% bleach) Parameter old normal early ARM impairmentold normal early ARM impairment rod-cone break 15.41 min 23.42 min  52%7.15 min 13.56 min 90% rod time  5.32 min 13.86 min 161% 5.74 min  7.72min 34% constant

TABLE 2 Dark adaptation parameter differences for peripheral vs. centraltarget spot location 12° inferior field 5° inferior field Parameter oldnormal early ARM impairment old normal early ARM impairment rod-conebreak 15.61 min 20.48 min 31% 14.82 min  24.03 min 62% rod time 10.11min 12.49 min 24% 9.96 min 16.80 min 69% constant

TABLE 3 Percentage of ARM patients exhibiting impaired rod- mediateddark adaptation (any parameter falling outside ±2 standard deviations ofthe normal mean value) Variables Percentage Kinetic Variable: Rod-conebreak 75% 2cd component recovery 56% 3^(rd) component recovery  0% Timeto baseline 55% Rod-mediated time constant 65% Any dark adaptationkinetics 85% Steady-State Variables: Baseline (pre-bleach) scotopic 25%Photopic sensitivity over 18⁰ radius 25% Scotopic sensitivity over 18⁰radius 20% Contrast sensitivity 35%

What is claimed:
 1. An apparatus for psychophysical measurement of darkadaptation in a test eye of a subject, said apparatus comprising: a. asystem for generating a target stimulus of a desired spectrum andintensity; b. a display for displaying said target stimulus to said testeye at a desired location, said display being in communication with saidsystem; c. an input device to permit said subject to input a reaction ofsaid subject to said target stimulus; and d. a controller incommunication with said system, said display and said input device, saidcontroller capable of controlling said system, recording at least one ofthe following: the reaction of said subject to said target stimulus, atime of said reaction, the intensity of said target stimulus at the timeof said reaction and the spectrum of said target stimulus at the time ofsaid reaction, and determining at least one threshold measurement orpartial threshold curve from said recording; wherein said at least onethreshold measurement or said partial threshold curve is predominatelyobtained in the second component of the rod mediated recovery.
 2. Theapparatus of claim 1 where the controller compares said at least onethreshold measurement or said partial threshold curve to correspondingvalues from a comparative database comprising a population ofindividuals, said controller storing said comparative database and theresults of said comparing.
 3. The apparatus of any of claim 1 where saidsystem is an optical system and said optical system comprises: a. afirst light source for generating said target stimulus, said first lightsource emitting a defined spectrum, or emitting a broad spectrum andsaid apparatus further comprising at least one optical element to selecta portion of the broad spectrum to generate a defined spectrum or acombination of the foregoing; and b. at least one neutral densityfilter, at least one electronic modulator or a combination of theforegoing to control the intensity of the target stimulus.
 4. Theapparatus of claim 1 where the display is a screen, a diffuser, an LEDdisplay, a liquid crystal display, a plasma display, or a CRT display ora combination of the foregoing.
 5. The apparatus of claim 3 furthercomprising at least one optical element selected from the groupconsisting of a shaping optic to shape the target stimulus, a directingoptic to direct the target stimulus to said display, an optical splitterand a calibration detector.
 6. The apparatus of claim 1 where saidsystem is an electronic system.
 7. The apparatus of claim 1 furthercomprising a second light source for generating a bleaching light. 8.The apparatus of claim 7 where said second light source is aphotographic flash or an electronic strobe.
 9. The apparatus of claim 7where the bleaching light inactivates 50% to 100% of the rhodopsinmolecules in said test eye.
 10. The apparatus of claim 7 where saidbleaching light has an intensity from 5.36 log scotopic Trolands/sec to7.65 log scotopic Trolands/sec.
 11. The apparatus of claim 1 furthercomprising an alignment element to ensure the target eye of said subjectis properly aligned.
 12. The apparatus of claim 11 where said alignmentelement comprises at least one of an adjustable chinrest, a targetfixation light, a bleaching fixation light or a camera to ensure andmonitor proper alignment of said test eye, said target fixation light.13. The apparatus of claim 3 where the first light source is at leastone light emitting diode.
 14. The apparatus of claim 13 where said atleast one light emitting diode emits a light having a spectrum effectivein stimulating the rod photoreceptors of said test eye.
 15. Theapparatus of claim 14 where said spectrum comprises at least onewavelength from 400 nm to 550 nm.
 16. The apparatus of claim 13 wheresaid at least one light emitting diode emits a broad spectrum light andthe at least one optical element selects a spectrum effective instimulating the rod photoreceptors of said test eye.
 17. The apparatusof claim 16 where said broad spectrum light is a white light.
 18. Theapparatus of claim 2 where said comparative database is stratified withrespect to stratification criteria and said stratification criteria areused to select a defined group of individuals within said comparativedatabase for use in said comparison step.
 19. The apparatus of claim 18where said stratification criteria is a dark adaptation status, a riskfactor or a demographic factor.
 20. The apparatus of claim 19 where saidrisk factors are selected from the group consisting of: age, smokingstatus, body mass index and status with regard to a disease state. 21.The apparatus of claim 19 where said demographic factors are selectedfrom the group consisting of age, ethnicity and gender.
 22. Theapparatus of claim 2 where the comparative database consists ofindividuals from 20 to 85 years of age.
 23. The apparatus of claim 2where the comparative database consists of individuals from 20 to 45years of age.
 24. The apparatus of claim 2 where the comparativedatabase consists of individuals that are not age-matched to thesubject.
 25. The apparatus of claim 2 where the comparative database ispurged of individuals who are determined to develop impaired darkadaptation status within a defined period of time after inclusion insaid comparative database.
 26. The apparatus of claim 18 where saiddefined group is selected based on at least one defining characteristicof said subject.
 27. The apparatus of claim 1 where the controllerfurther comprises a noise reduction protocol and said at least onethreshold measurement or said partial threshold curve is subject to saidnoise reduction protocol.
 28. The apparatus of claim 27 where the noisereduction protocol is a non-destructive noise reduction protocol. 29.The apparatus of claim 38 where the non-destructive noise reductionprotocol is threshold guidance, curve guidance or a combination of theforegoing.
 30. The apparatus of claim 29 where threshold guidancecomprises comparing a presumptive threshold measurement to a basethreshold measurement or a model-fit of said base threshold measurement,determining if said presumptive threshold measurement falls within apredetermined window of said base threshold measurement or model-fit anddiscarding said presumptive threshold measurements that do not fallwithin said window or replacing said presumptive threshold measurementsthat do not fall within said window.
 31. The apparatus of claim 29 wheresaid curve guidance comprises subjecting said at least one thresholdmeasurement to a statistical function of a defined width anchored tosaid at least one threshold measurement or a model-fit of said at leastone threshold measurement, thereby obtaining at least one thresholdvalue, and discarding those of said threshold values that fall outsideof said width.
 32. The apparatus of claim 2 where said controller usesthe results of said comparison to determine a dark adaptation status ofsaid subject.
 33. The apparatus of claim 32 where said dark adaptationstatus is considered impaired if one or more of said at least onethreshold measurement or said partial threshold curve meets animpairment criterion.
 34. The apparatus of claim 33 where saidimpairment criterion is met when said comparing is conducted using adefined group from said comparative database consisting of healthyindividuals and one or more of said at least one threshold measurementor said partial threshold curve falls outside of a reference range ofcorresponding measurements from said defined group.
 35. The apparatus ofclaim 33 where said impairment criterion is met when said comparing stepis conducted using a defined group from said comparative databaseconsisting of individuals diagnosed with a disease state and one or moreof said at least one threshold measurement or said partial thresholdcurve falls within a reference range of said corresponding measurementsfrom said defined group.
 36. The apparatus of claim 34 where saidreference range is selected from the group consisting of the mean plusor minus two standard deviations of the mean, cut points, receiveroperating curves, and confidence intervals.
 37. The apparatus of claim35 where said reference range is selected from the group consisting ofthe mean plus or minus two standard deviations of the mean, cut points,receiver operating curves, and confidence intervals.
 38. The apparatusof claim 33 where said status of impaired dark adaptation of saidsubject indicates said subject is at risk for a disease state selectedfrom the group consisting of age related macular degeneration, vitamin Adeficiency, Sorsby's Fundus Dystrophy, late autosomal dominant retinaldegeneration, retinal impairment related to diabetes and diabeticretinopathy.
 39. The apparatus of claim 33 where said status of impaireddark adaptation of said subject indicates said subject is suffering froma disease state selected from the group consisting of age relatedmacular degeneration, vitamin A deficiency, Sorsby's Fundus Dystrophy,late autosomal dominant retinal degeneration, retinal impairment relatedto diabetes and diabetic retinopathy.
 40. The apparatus of claim 33where said controller uses at least one of the results of saidcomparison and the status of impaired dark adaptation to suggest adiagnosis that said subject is at risk for a disease state selected fromthe group consisting of age related macular degeneration, vitamin Adeficiency, Sorsby's Fundus Dystrophy, late autosomal dominant retinaldegeneration, retinal impairment related to diabetes and diabeticretinopathy.
 41. The apparatus of claim 33 where said controller uses atleast one of the results of said comparison and the status of impaireddark adaptation to suggest a diagnosis that said subject is sufferingfrom a disease state selected from the group consisting of age relatedmacular degeneration, vitamin A deficiency, Sorsby's Fundus Dystrophy,late autosomal dominant retinal degeneration, retinal impairment relatedto diabetes and diabetic retinopathy.
 42. The apparatus of claim 32where said dark adaptation status is determined in less than 20 minutes.43. The apparatus of claim 32 where said dark adaptation status isdetermined in less than 10 minutes.
 44. The apparatus of claim 32 wheresaid dark adaptation status is determined with at least 80% specificityor 80% sensitivity.
 45. The apparatus of claim 32 where said darkadaptation status is determined with at least 90% specificity or 90%sensitivity.